Learning Objectives How to Get Your Kids to Eat
How to Get Your Kids to Eat Learning Objectives Introduction Identify Resistant Eaters Assessment and baseline data Review oral-motor delays and treatment strategies Review Sensory based Eating challenges and treatment strategies Functional Behavior Assessment and Behavior Interventions Plans for mealtimes to address behavioral issues Dr. Lori Ernsperger, Ph.D., BCBA-D www.loriernsperger.com [email protected] Copyright 2014 Ernsperger Copyright 2014 Ernsperger Recipe For Success! Learning Objectives Behavioral difficulties at mealtimes Conducting a FBA Write a feeding behavior plan Develop antecedent based interventions strategies Discuss escape extinction procedures It starts with you. Be fully present and fully attentive when you are with the child Want the very best for the child and family. Know that they are doing their best at the moment. If you make a mistake, try again Copyright 2014 Ernsperger 5 Common Characteristics Resistant Eaters Copyright 2014 Ernsperger Limited Food Selection Eats less than 5-20 foods ◦ As little as 1 or 2 foods • Eating Continuum • Characteristics Selects only foods with a similar trait 1. Limited Food selection 2. Limited Food groups 3. Anxiety around new foods 4. Food Jags 5. Diagnosed with a DD ◦ Only white foods Limited in taste and texture ◦ Pureed foods only Bottle fed or formula past developmental stage ◦ 24 months Copyright 2014 Ernsperger Copyright 2014 Ernsperger 1 Introduction to Resistant Eaters Limited Food Groups Nutritional deficiencies Breads and cereal group • Prevalence ◦ Carb lovers – 60-75% of children on the ASD – 5 Times more likely to have behavioral challenges at mealtimes – 80% of children with severe mental retardation – 30-45% of typically developing children – Developmental scale May eat some from the meat group ◦ Chicken nuggets from McDonalds ◦ Wendy’s French Fries Very few fruits or vegetables ◦ Bananas-sweet ◦ Apples- no skin Copyright 2014 Ernsperger Copyright 2014 Ernsperger Anxiety and New Foods Developmental Delays • Medical and neuromuscular disorders – CP and GERD – Down Syndrome • Premature at birth – Window for introducing soft munchables and solids • ASD • • • • • • Tantrums when introduced to a new food Strong phobic reaction to new foods Refuses to approach the table Gagging or vomiting Highly sensitive olfactory system New DSM-5 diagnosis Copyright 2014 Ernsperger Food Neophobia • • • • • Fear of new foods Typically developing stage for 2-3 year olds Outgrown by age 5 May linger into adulthood without treatment Food Neophobia Scale (Pliner and Hobden) – How did you score? Copyright 2014 Ernsperger Copyright 2014 Ernsperger Mealtime Activity Intake Form- Eating Profile • Review student strengths and weaknesses • Review sensory and motor needs • Identify food jags • Medical Assessment – Consultation Copyright 2014 Ernsperger 2 Oral-Motor Impairment Mealtime Plan • Oral-Motor Based Interventions • Sensory Based Interventions • Behaviorally Based Interventions • Combination • Caution: stay within your competency Assessment by a highly qualified OT or SLP Definition: Movements of the muscles in the mouth, lips, tongue, cheeks, and jaw. Includes the functions: biting, crunching, chewing, sucking, & licking Copyright 2014 Ernsperger Copyright 2014 Ernsperger Causation: Oral Motor Skills • “Sometimes children get “Stuck” in their oral-motor development. We refer to this as a limitation in their development. There are many reasons for this limitation. The limit is now a behavior that can be treated—Not a forever label.” Suzanne Evans Morris During feeding, poor oral-motor skills may lead to: • Gagging/frequent choking • Drooling • Difficulty keeping food down • Difficulty transitioning to different textured foods • Difficulty sucking, chewing, swallowing • Picky eating habits (avoiding textures, temperature, tastes) Copyright 2014 Ernsperger Copyright 2014 Ernsperger Low Muscle Tone Treatment Strategies: Oral Motor • Tongue – Reduces strength for safe eating – Reduces sustained chewing – Pockets food • Cheeks and lips – Limited facial movement – Mouth to hang open – Drooling Copyright 2014 Ernsperger • • • • Oral awareness and oral stimulation Mouth Madness by Catherine Orr “Can Do” Oral Motor Cards (www.superduperinc.com) Oral-Motor Activities for Young Children (www.linguisystems.com) • Mouth Box – Rubbermaid container Copyright 2014 Ernsperger 3 Caution • Never enter a child’s mouth without being highly qualified and highly effective • Appropriate credentials, licensed, and on-going training Copyright 2014 Ernsperger Mouth-Toys for Resistant Eaters • Appropriate for all ages – Action figures – Select items designed for chewing • Sensory discrimination – Textures • Oral-motor awareness • Use mouth toys to introduce new foods • Teaches oral-motor coordination • • • • • Oral Motor Skills • Phases of Swallowing – Oral Phase- 2 parts – Pharyngeal phase- movement of the bolus – Esophageal phase- to the stomach • Cracker Activity – Texture – Tongue Control – Placement Copyright 2014 Ernsperger TX: Stretchy Tubing • • • • • • Sensory feedback Biting Chewing Jaw stabilization Sucking Dip into a variety of flavors Copyright 2014 Ernsperger Copyright 2014 Ernsperger Respiration and Eating Tx: Blowing Activities You can’t eat if you can’t breathe Nasal cavity, trachea, lungs Breathing, swallowing, and talking Coordination Important when feeding a child- pace of the meal Copyright 2014 Ernsperger • • • • Bubble Blower Birthday horns Straws and cotton balls Practice deep breathing Copyright 2014 Ernsperger 4 Caution: Chewing Activities • Dental Check • Tina’s first dental check Autism Speaks Dental Tool Kit www.autismspeaks.org Copyright 2014 Ernsperger Sensory Based Eating Challenges • • • • The following is a brief overview Work within your competency Experts in the field of OT Scientifically based research published in peer reviewed journals Sensory-Based Eating Challenges • Dr. A Jean Ayres- pioneer in OT • Our brain: – Receives sensory information from our bodies and surroundings – Interprets these messages – Organizes a purposeful response Copyright 2014 Ernsperger Proprioceptive System & Mealtimes Definition Adjusting/grading jaw opening Hold utensils with too much/too little force Knowing body position in relation to objects on table Grading movement to drink Weighted utensils Weighted drinking cup Crazy Straws Thicken liquids Copyright 2014 Ernsperger Copyright 2014 Ernsperger Vestibular System & Mealtimes Gustatory System & Mealtimes • Definition • Focus all attention on moving sensations • Quick movement – alerting • Slow movements - calming • Muscle tone • Max Copyright 2014 Ernsperger Decreased taste sensitivity (inedible objects, spicy foods, extreme temperatures) Increased taste sensitivity (object to textures/temperatures, gag) “Supertasters” Medications can change tastes Sweet-tasting addiction Copyright 2014 Ernsperger 5 Olfactory System & Mealtimes 75% of taste perceptions depend on efficient sense of smell Olfactory stimulus goes to the limbic system (emotions and inner drive) – strong association with memory storage Odor & childhood memory? Copyright 2014 Ernsperger Auditory/Visual Calming visual input: dull finish utensils lighting table setting Music with a slow tempo, and regular sustained rhythm slows down breathing and heart rhythms – lead to relaxation Copyright 2014 Ernsperger Tx: Olfactory • Food at room temperature • Limiting number of smells • Calming activities: blowing proprioceptive input drinking water sucking on ice Copyright 2014 Ernsperger Review • Highly qualified professionals to assess for oralmotor and sensory based feeding challenges • Multidisciplinary teams • Parental involvement • Combination approach must include Behavior Intervention Plan – Behavioral difficulties interfere with mealtimes even after physiological issues have been addressed • “The Perfect Meal” review Copyright 2014 Ernsperger Principles of ABA abainternational.org Feeding Behavior Intervention Plan Antecedent Behavior Consequence ACTION PLAN Copyright 2014 Ernsperger Based on principles of behavioral learning theory Based on behavioral determinism, behavior does not occur randomly, it is predictable and lawful and follows a set of scientific principles Data based decision making Based on socially significant behaviors that will improve the outcome for the student An emphasis on reinforcing appropriate behavior rather than punish inappropriate behavior Focus on observable behaviors that are clear and concise Copyright 2014 Ernsperger 6 ABA: Three Term Contingency Functional Behavior Assessment • Functional Behavior Assessment (EBP) • FBA focuses on investigating the nature of the target behavior. • As a team, we must ask ourselves “why?” is the child exhibiting this behavior at mealtimes? • What purpose does the behavior serve for the child? Copyright 2014 Ernsperger Copyright 2014 Ernsperger Steps to completing a FBA and BIP Feeding Plan 1. 2. 3. 4. 5. 6. 7. Antecedent Based Interventions • Assess antecedents which are currently maintaining behavioral challenges at mealtimes • Too much food? • Portion Size? • Mealtime Environment • Interview parents Identify the Target Behavior Data Collection Develop a Hypothesis Write the BIP Teach Replacement skills Modify Antecedents and Environment Identify Reinforcement Evaluate Plan; progress monitoring Copyright 2014 Ernsperger Antecedent Based Interventions Role of the family Family schedules, settings, and serving sizes Problem behaviors reinforced with attention by parents Lack of knowledge and awareness of interfering problem behaviors Copyright 2014 Ernsperger Copyright 2014 Ernsperger Parental Responsibility • Myth: Good parents are responsible for getting their child to eat. – “Parents and professionals working with children are responsible for preparing and providing a balanced meal at an appropriate schedule and setting. The CHILD is solely responsible for whether they eat and how much they eat.” – Ellyn Satter, Secrets of Feeding a Healthy Family Copyright 2014 Ernsperger 7 Antecedent Mealtime Activity “Guess Who’s Coming to Dinner” List 4 Beliefs you have in your family about eating • How do you feel about mealtimes • Your role and responsibility • Personal beliefs about meals and food • Generational rules Environment Positioning Rules and Routines Visual Supports Social Narratives ANTECEDENT –B - C Copyright 2014 Ernsperger Copyright 2014 Ernsperger ABI: Visual Supports • Schedule ABI: Organize Environment Create a Consistent Setting – Written and posted ◦ Eating and drinking is done at the table ◦ Supportive and nurturing • Understandable to the child – Timers – Includes snacks – No grazing and only water between meals Role model good eating habits Do not discuss the child’s eating habits during the meal ◦ Limit distractions Copyright 2014 Ernsperger ABI: Portion Size and Food Selection Food selection ◦ Always have one preferred food item at every meal The preferred item is the prompt Fade prompt over time ◦ Pair a new food with a preferred food ◦ Child-friendly foods ◦ Temperature Portion size ◦ Age appropriate plates and utensils ◦ Measuring spoons and cups ◦ Less is best Copyright 2014 Ernsperger Copyright 2014 Ernsperger Food Selection: How to Choose? • Resistance – Graham cracker v. bagel • Sensory Input – Pickles v. mild cheese • Size – Small pretzel v. sandwich • Shape – Veggie stixs v. toast Copyright 2014 Ernsperger 8 “The mouth and body interact in partnership to support sufficient eating. The way in which a person moves the body, makes a big difference in the way in which the mouth moves for eating.” Suzanne Evans Morris www.new-vis.com Copyright 2014 Ernsperger Tx: Behavior and Mealtimes • Check environmental factors • Set a routine pre and post meal – Transition activities-auditory – Involve child in pre-meal activities • Written rules – Teach routines • Stick with the schedule ABI: Positioning Consult with an OT What position is the trunk? How are the shoulders supported? What type of head control? What supports for the hips and pelvis? Do the feet have adequate support? Copyright 2014 Ernsperger Social Narratives (EBP) Select a clear goal or desired outcome Write in the first person Use Wh questions as an outline Write positive behaviors and outcomes Visual and concrete information Consider a student’s cognitive level Provides the individual with the opportunity to practice a new or difficult behavior Include already acquired skills (strengths) Antecedent Strategy Copyright 2014 Ernsperger Write a Social Narrative • Answer the W questions • What are the observable and measurable behaviors? • Positive Outcome • Share with group • Review EBP Checklist • Share with group Copyright 2014 Ernsperger Copyright 2014 Ernsperger Teach about Foods Food Rich Environment ◦ repetition Teach the child about the food pyramid Sort foods by colors If they know moreThey will eat more! Copyright 2014 Ernsperger 9 Antecedent: Teach Mands Requesting Skills • Review Feeding BIP – Does it include teaching the child to request • Teach requesting skills – Basic communication needs • Functional Communication Training – EBP • Verbal Behavior: – Skinner 1. Manding pairs the adult with the delivery of food specific to the mand. (preferred food item or reinforcer) 2. Manding is essential for social communication at mealtimes interaction. 3. Manding is verbal behavior that produces immediate benefit for the student and strengthens it. 4. Development of a strong manding repertoire may be essential for the development of other types of verbal behavior (ex. tacting, intraverbal, etc.). Manding teaches a student that behavior is valuable • What is a mand? Copyright 2014 Ernsperger Copyright 2014 Ernsperger Interventions Implemented During Treatment/Mealtime • Shaping – Task Analysis of Steps to Eating During Mealtimes Interventions at mealtimes Introducing new foods Compliance and High-P Programs A- BEHAVIOR - C • • • • • • Kay Toomey SOS Approach 30 Steps to Eating Being in the room with a new food Chewing and swallowing independently “Just Try It!” Re-define “trying” Copyright 2014 Ernsperger Copyright 2014 Ernsperger Naturalistic Interventions: Introducing New Foods • Prompt and prompt fading – Preferred foods are a prompt to be paired with the new food item – SD plus prompt • Modeling • Children learn to eat through their senses – Developmentally appropriate practices • Playful and fun – Naturalistic behavioral Interventions (EBP) – Child-centered as much as possible • 10-15 successful trials at each stage – Visual models – Adult models – Peer models – Video Modeling – Systematic desensitization – How do we learn about new foods? • Grace Copyright 2014 Ernsperger Copyright 2014 Ernsperger 10 Non-Compliance at Mealtimes Intervene with a High-P Program • Noncompliance and escape behavior are learned • Intervene at first signs of non-compliance or a “negative tilt” • High-probability programs focus on mastered skills • What skills or behaviors can the student easily master? • Rote Memory • 2+2 =? • Receptive labeling – Marsha Dunn Klein • Review crisis cycle – “Touch Nose” Copyright 2014 Ernsperger Copyright 2014 Ernsperger High - P A-Behavior-C Steps for High-P Program Examples of High-P program • Intervene at first signs of noncompliance Case Study • • • • ◦ Compliance Form ◦ ◦ ◦ ◦ – trigger Student at recess- ESY What is the probability of compliance? Identify 3-5 mastered skills Receptive Labels: Touch Cinderella Touch Jasmine Touch Bell Touch Tiana Copyright 2014 Ernsperger Have materials accessible Give instructions clear and concise Reinforce Rapid 3-5 high-p instructions followed by lowprobability command (stand-up) • If non-compliance continues; repeat instructions and increase reinforcement Copyright 2014 Ernsperger Negative Reinforcement Negative Reinforcement Escape Extinction Positive Reinforcement Data Collection A – B - CONSEQUENCE Copyright 2014 Ernsperger • Removal of an non-preferred or aversive (new food) which maintains future rates of behavior • Student’s behavior at mealtimes has been maintained or increased over time based on reinforcement for leaving the meal • Attention from parents or other adults • Escape from food • Preferred foods are provided at a later time not on the schedule Copyright 2014 Ernsperger 11 Escape Extinction at Mealtimes Part Three: Consequence • Three Term Contingency • Data based decision with IEP team • Competency: area of expertise – A-B-C – Focus on the Consequence – Difficult for parents • School district policies: restraint? – Blocking a student from escaping • Review high-probability and identify compliance levels • Carefully monitor level of compliance • Teach student to request a break • Compliance at mealtimes behaviors will only repeated if they are immediately followed by reinforcement • Reinforcement increases the likelihood for the student to exhibit compliant behaviors in the future at mealtimes • Preference Assessment vs. Reinforcement Copyright 2014 Ernsperger Copyright 2014 Ernsperger Part Three: Reinforcement Consequence: Reinforcement • Rules for reinforcement Schedule of reinforcement – No edible reinforcement • Rotate reinforcement • Select the most powerful reinforcement for compliance program • Reinforcement is not bribery • Change your TV viewing behavior? ◦ Immediate vs delayed ◦ Reinforce all levels of the food hierarchy ◦ Deprivation is a “good thing” Token Economy ◦ How many? How often is the exchange? Picture Token Boards ◦ Computer – Stop watching your favorite shows? – How much money? Copyright 2014 Ernsperger Copyright 2014 Ernsperger Data Based Decisions at Mealtimes Mealtime BIP Data collection • Collect Data • Graph Data – Aimline • Determine if the target behavior has decreased and/or • Has the alternative or replacement behavior increased • Analyze the quality of the reinforcer Copyright 2014 Ernsperger • Duration: how long at mealtimes? • Frequency or rate: Number of Bites – Golf counter – Hand-counter – Masking tape – Pennies Copyright 2014 Ernsperger 12 Aimline: Connect Baseline with IEP Goal Independent Bites: Goal = 4 Data Analysis • Data driven decision making • After three data points, determine: – Is the child meeting the goals? – If YES, proceed with mealtime interventions. – If NO, make changes to mealtime environment, schedule, reinforcement, antecedents – Self-reflection Copyright 2014 Ernsperger Copyright 2014 Ernsperger Review Mealtime BIP • • • • Oral-motor and sensory based plan Mealtime Behavior Intervention Plan Data Collection? Long-term goals Copyright 2014 Ernsperger 13 Mealtime Behavior Intervention Plan A Antecedent Context Mealtime environment Before the behavior occurs Therapy environment B Observable Measurable Specific Target behavior at mealtimes or during therapy C Consequence After the behavior occurs Function of behavior Adult reaction to child’s behavior Hypothesis Statement: (When this occurs …/The child does …../In order to ….) _______________________________________________________________________________ _______________________________________________________________________________ Antecedent Based Interventions: mealtime environment, visual supports: 1. 2. 3. Preference assessment: 1. 2. 3. Replacement or Alternative Skills: Request a break, functional communication 1. 2. Copyright Ernsperger Food Neophobia Scale Pliner & Hobden *Mark the following when answering items 2, 3, 5, 7, & 8 1=disagree extremely 2=disagree moderately 3=disagree slightly 4=neither agree nor disagree 5=agree slightly 6=agree moderately 7=agree extremely *Mark the following when answering items: 1,4,6,9, & 10 (bold and italics) 1=agree extremely 2=agree moderately 3=agree slightly 4=neither agree nor disagree 5=disagree slightly 6=disagree moderately 7=disagree extremely ____ 1. I am constantly sampling new and different foods. ____ 2. I don’t trust new foods ____ 3. If I don’t know what is in a food, I won’t try it. ____ 4. I like foods from different countries ____ 5. Ethnic food looks too weird to eat. ____ 6. At dinner parties, I will try a new food. ____ 7. I am afraid to eat things I have never had before. ____ 8. I am very particular about the foods I will eat. ____ 9. I will eat almost anything. ____ 10. I like to try new ethnic restaurants. * If parents are rating their child, change each item to include “my child” References and Resources Lori Ernsperger, Ph.D., BCBA-D [email protected] Just Take a Bite: Easy, Effective Answers to Food Aversion and Eating Challenges (2004). Lori Ernsperger & Tania Stegen Hanson. 1. Pre-Feeding Skills, A Comprehensive Resource For Mealtime Development, 2nd edition (2000). Suzanne Evans Morris, PH.D., CCC-SLP and Marsh Dunn Klein, M.ED., OTR/L. Therapy Skill Builders. www.new-vis.com 2. The Out-Of-Sync Child Carol Stock Kranowitz, M.A. Future Horizons. 3. The Out-Of-Sync Child Has Fun Carol Stock Kranowitz, M.A. Sensory Resources. 4. How to get Your Child to Eat, But Not Too Much, (1987). E. Satter, Bull Publishing. 5. Secrets of Feeding a Healthy Family (1999). E. Satter, Kelcy Press. 6. Normal Development of Functional Motor Skills, Rona Alexander, Ph.D., CCCSP; Regi Boehme, OTR and Barbara Cupps, PT. 7. Mouth Madness: Oral Motor Activities for Children, (1998). Catherine Orr, M.A., OTR. Therapy Skill Builders. 8. Pliner and Hobden (1992). Development of a Scale to Measure the Trait of Food Neophobia in Humans, Appetite, v. 19. 9. North American Society for Pediatric Gastroenterology, Hepatology and Nutrition www.naspgn.org, 215-333-0808. 10. Applying Sensory Integration Principles Where Children Live, Learn, and Play: www.sensoryresources.com (video) 11. www.usda.gov, US Department of Agriculture and www.choosemyplate.gov 12. Dole Company, Five a day Program: On-line catalogue for educators. www.5aday.com. 13. The Educators Guide to Feeding Children with Disabilities, Lowman & Murphy. Paul H. Brookes Co., www.pbrookes.com. 14. NCES catalogue of nutrition and education resources: www.ncescatalog.com. 15. Abilitations Catalogue: products specializing in positioning and oral motor development. www.abilitations.com. 16. Keys to Success for Teaching Students with Autism (2003). Ernsperger, Lori. Future Horizons Publishing. 17. Childhood Feeding Disorders, Kedesdy & Budd (1998). Paul Brookes Pub., www.brookespublishing.com. 18. Oral-Motor Activities for Young Children (1996). Mackie, E. Linguisystems Inc. www.linguisystems.com 19. Therapro: www.theraproducts.com 20. Food Chaining (2007). Fraker, Fishbein, Cox, and Walbert. Da Capo Press. 21. Get Permission Approach (video) with Marsha Dunn Klein. www.mealtimenotions.com 22. Talk Tools Catalogue www.talktoolstm.com Eating Profile - Brief Name: _______________________________________ Age: ___________________ Accepted Foods; Preferred foods; Selective Brands; Utensils; Other Rituals (Include Food Jags): Preferred Textures, Colors, Flavors: Sensory Issues: Other Medical Issues (GERD); diagnosis: Physical Limitations (include oral-motor delays); Assessment data: Medications and Side-Effects of Medicine: Parental Concerns: Goal Statement of Feeding Program:
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